Intensive Versus Standard Treatment of Hyperglycemia in Acute Ischemic Stroke Patient: A Randomized Clinical Trial Subgroups Analysis

Benefit from blood glucose (BG) control during acute ischemic stroke may depend on glycemic parameters. We evaluated for associations between the SHINE (Stroke Hyperglycemia Insulin Network Effort) randomized treatment group and the SHINE predefined 90-day functional outcome, within-patient subgroups defined by various glycemic parameters.

Validation of American Thyroid Association Ultrasound Risk Assessment of Thyroid Nodules Selected for Ultrasound Fine-Needle Aspiration

OBJECTIVE

The aim of this study was to validate the American Thyroid Association (ATA) sonographic risk assessment of thyroid nodules.

METHODS

The ATA sonographic risk assessment was prospectively applied to 206 thyroid nodules selected for ultrasound-guided fine-needle aspiration (US-FNA), and analyzed with The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), as well as surgical pathology for the subset undergoing surgical excision.

RESULTS

The analysis included 206 thyroid nodules averaging 2.4 cm (range 1-7 cm; standard error of the mean 0.07). Using the ATA US pattern risk assessment, nodules were classified as high (4%), intermediate (31%), low (38%), and very low (26%) risk of malignancy. Nodule size was inversely correlated with sonographic risk assessment, as lower risk nodules were larger on average (p < 0.0001). Malignancy rates determined by cytology/surgical pathology were high 100%, intermediate 11%, low 8%, and very low 2%, which were closely aligned with ATA malignancy risk estimates (high 70-90%, intermediate 10-20%, low 5-10%, and very low 3%). ATA US pattern risk assessment also appropriately predicted the proportion of nodules classified as malignant or suspicious for malignancy through TBSRTC classification-high (77%), intermediate (6%), low (1%), and very low 0%-as well as benign TBSRTC classification-high (0%), intermediate (47%), low (61%), and very low (70%) (p < 0.0001). Malignancy rates of surgically excised, cytologically indeterminate nodules followed ATA sonographic risk stratification (high 100%, intermediate 21%, low 17%, and very low 12%; p = 0.003).

CONCLUSION

This prospective study supports the new ATA sonographic pattern risk assessment for selection of thyroid nodules for US-FNA based upon TBSRTC and surgical pathology results. In the setting of indeterminate cytopathology, nodules categorized as atypia of undetermined significance/follicular lesion of undetermined significance with ATA high-risk sonographic patterns have a high likelihood of being malignant.

Thyroid Ultrasound-Guided Fine-Needle Aspiration Cytology Results: Observed Increase in Indeterminate Rate over the Past Decade

Objectives To evaluate changes in distribution of reported thyroid nodule fine-needle aspiration (FNA) cytopathology results since implementation of the Bethesda classification and revised 2015 American Thyroid Association (ATA) guidelines for selecting nodules for biopsy. Study Design Retrospective review. Setting Tertiary academic medical center. Subjects and Methods Evaluation of ultrasound (US)-guided thyroid FNA by a single surgeon using 2015 ATA nodule selection criteria and Bethesda reporting on 211 thyroid nodules in a 1-year period (2015). Comparison is made to an earlier sample wherein any nodule >1 cm underwent US FNA with cytology reported prior to Bethesda consensus (2006). Results The current cohort involved mostly women (79%); nodules ranged from 1 to 7 cm (mean ± SEM, 2.4 ± 0.07 cm). Mean ± SEM age was 53.5 ± 1.1 years. Bethesda reporting yielded 6% nondiagnostic, 57% benign, 3% malignant, and 34% indeterminate (27% atypia of undetermined significance [AUS]/follicular lesion of undetermined significance [FLUS], 4% follicular neoplasm [FN]/Hürthle neoplasm [HN], and 2% suspicious for malignancy [SFM]). The malignancy rate in indeterminate nodules was 26% (18% AUS/FLUS, 33% FN/HN, and 80% SFM). Age, sex, or nodule size did not correlate with indeterminate cytology. The comparator sample of 447 nodules had significantly different distribution, with 7% nondiagnostic, 80% benign, 5% malignant, and 8% indeterminate ( P < .00001). Conclusion We observed a significantly increased proportion of indeterminate cytology and corresponding decrease in benign nodules compared with an earlier sample, predominately from an increase in AUS/FLUS. Multiple factors are likely involved, including selection of sonographically suspicious nodules for biopsy based upon 2015 ATA guidelines coupled with cytopathological interpretation by a new generation of cytopathologists trained in the era of Bethesda reporting; further study is required to make a definitive conclusion.

Efficacy of Thyroid Hormone Suppression for Benign Thyroid Nodules: Meta-Analysis of Randomized Trials

OBJECTIVE: To determine the efficacy of thyroid hormone suppressive therapy (THST) to decrease benign thyroid nodule volume.

DESIGN: Meta-analysis.

METHODS: Systematic search using electronic databases (PubMed, Medline, Cochrane Library) through August 2004, paper review, and contacting experts and drug manufacturers. Only randomized controlled studies of THST vs no treatment or placebo, for reduction of benign thyroid nodule volume, were included. Exclusion criteria were: >6-month treatment, lack of ultrasound volume measurement, and region of endemic goiter. Primary outcome was clinically relevant nodule volume reduction (>50%), with a random effects model (RevMan4.2).

RESULTS: Nine randomized trials were included (609 subjects). Subjects were 88% more likely to experience >50% nodule volume reduction with THST than placebo or no treatment (relative risk = 1.88; 95% CI = 1.18-3.01; P = 0.008). However, 8 subjects must be subjected to the risk of cardiac and skeletal side effects from THST, for one to benefit from therapy (number needed to treat = 8, risk difference = 0.13; 95% CI = 0.06-0.19; P = 0.0003). Sensitivity analysis reveals that 15 null studies would have to have been missed to reverse statistical significance (fail-safe N = 15). Review of the only study with long-term treatment (5 years) suggests no significant difference in nodule volume reduction between THST and placebo. Further, studies with follow-up after THST withdrawal demonstrate rapid increase in thyroid nodule and goiter volumes.

CONCLUSION: THST appears more likely than placebo or no treatment to significantly reduce benign thyroid nodule volume, but long-term treatment may be less effective and regrowth is likely following cessation of therapy. Given the risks of THST, routine use is not recommended for benign nodules.

Diabetes Transition Care From an Inpatient to Outpatient Setting in a Veteran Population: Quality Improvement Pilot Study

PURPOSE

The purpose of the study was to evaluate a diabetes transition care program in a population of veterans with diabetes by calculating 30-day readmission rates and assessing glycemic control.

METHODS

Hospitalized patients with poorly controlled diabetes were identified to participate in the diabetes transition care program. The program included follow-up through a postdischarge telephone call by the diabetes educator, with an opportunity for a face-to-face clinic visit. A retrospective before-and-after study design was used. Analysis included calculating the readmission rate and the pre- and postintervention A1C rates to evaluate the intervention.

RESULTS

Of the 40 participants, 100% completed the intervention. All 40 participants received a postdischarge telephone call as follow-up, with 20% presenting for a face-to-face visit. The 30-day readmission rate for the cohort was 10%, in comparison to 14.3% for patients who did not receive the intervention but were otherwise comparable. For those who had repeat A1C measurements conducted 2 to 8 months after time of enrollment in the program (n = 33), average A1C declined -2.2%, from 11.3% (100 mmol/mol) to 9.1% (76 mmol/mol).

CONCLUSIONS

Diabetes-specific transition of care for those with complex psychiatric, medical, and social needs was feasible, with good outcomes in hospital readmission rates and glycemic control, when executed by an adult nurse practitioner who was the inpatient diabetes educator.

Pathways to quality inpatient management of hyperglycemia and diabetes: a call to action

Currently patients with diabetes comprise up to 25-30% of the census of adult wards and critical care units in our hospitals. Although evidence suggests that avoidance of hyperglycemia (>180 mg/dL) and hypoglycemia (<70 mg/dL) is beneficial for positive outcomes in the hospitalized patient, much of this evidence remains controversial and at times somewhat contradictory. We have recently formed a consortium for Planning Research in Inpatient Diabetes (PRIDE) with the goal of promoting clinical research in the area of management of hyperglycemia and diabetes in the hospital. In this article, we outline eight aspects of inpatient glucose management in which randomized clinical trials are needed. We refer to four as system-based issues and four as patient-based issues. We urge further progress in the science of inpatient diabetes management. We hope this call to action is supported by the American Diabetes Association, The Endocrine Society, the American Association of Clinical Endocrinologists, the American Heart Association, the European Association for the Study of Diabetes, the International Diabetes Federation, and the Society of Hospital Medicine. Appropriate federal research funding in this area will help ensure high-quality investigations, the results of which will advance the field. Future clinical trials will allow practitioners to develop optimal approaches for the management of hyperglycemia in the hospitalized patient and lessen the economic and human burden of poor glycemic control and its associated complications and comorbidities in the inpatient setting.

Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis

OBJECTIVES

Hyperglycemia during critical illness is common and is associated with increased mortality. Intensive insulin therapy has improved outcomes in some, but not all, intervention trials. It is unclear whether the benefits of treatment differ among specific patient populations. The purpose of the study was to determine the association between hyperglycemia and risk- adjusted mortality in critically ill patients and in separate groups stratified by admission diagnosis. A secondary purpose was to determine whether mortality risk from hyperglycemia varies with intensive care unit type, length of stay, or diagnosed diabetes.

DESIGN

Retrospective cohort study.

SETTING

One hundred seventy-three U.S. medical, surgical, and cardiac intensive care units.

PATIENTS

Two hundred fifty-nine thousand and forty admissions from October 2002 to September 2005; unadjusted mortality rate, 11.2%.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A two-level logistic regression model determined the relationship between glycemia and mortality. Age, diagnosis, comorbidities, and laboratory variables were used to calculate a predicted mortality rate, which was then analyzed with mean glucose to determine the association of hyperglycemia with hospital mortality. Hyperglycemia was associated with increased mortality independent of illness severity. Compared with normoglycemic individuals (70-110 mg/dL), adjusted odds of mortality (odds ratio, [95% confidence interval]) for mean glucose 111-145, 146-199, 200-300, and >300 mg/dL was 1.31 (1.26-1.36), 1.82 (1.74-1.90), 2.13 (2.03-2.25), and 2.85 (2.58-3.14), respectively. Furthermore, the adjusted odds of mortality related to hyperglycemia varied with admission diagnosis, demonstrating a clear association in some patients (acute myocardial infarction, arrhythmia, unstable angina, pulmonary embolism) and little or no association in others. Hyperglycemia was associated with increased mortality independent of intensive care unit type, length of stay, and diabetes.

CONCLUSIONS

The association between hyperglycemia and mortality implicates hyperglycemia as a potentially harmful and correctable abnormality in critically ill patients. The finding that hyperglycemia-related risk varied with admission diagnosis suggests differences in the interaction between specific medical conditions and injury from hyperglycemia. The design and interpretation of future trials should consider the primary disease states of patients and the balance of medical conditions in the intensive care unit studied.

Molecular testing for mutations in improving the fine-needle aspiration diagnosis of thyroid nodules

CONTEXT

Thyroid nodules are common in adults, but only a small fraction of them are malignant. Fine-needle aspiration (FNA) with cytological evaluation is the most reliable tool for cancer diagnosis in thyroid nodules. However, 10-40% of nodules are diagnosed as indeterminate by cytology, making it difficult to optimally manage these patients.

OBJECTIVE

The aim of this study was to establish the feasibility and role of testing for tumor-specific mutations in improving the FNA diagnosis of thyroid nodules.

DESIGN

The prospective study included 470 FNA samples of thyroid nodules from 328 patients. At the time of aspiration, a small portion of the material was collected and tested for BRAF, RAS, RET/PTC, and PAX8/PPARgamma mutations. The mutational status was correlated with cytology and either surgical pathology diagnosis or follow-up (mean, 34 months).

RESULTS

A sufficient amount of nucleic acids were isolated in 98% of samples. Thirty-two mutations were found, including 18 BRAF, eight RAS, five RET/PTC, and one PAX8/PPARgamma. The presence of any mutation was a strong indicator of cancer because 31 (97%) of mutation-positive nodules had a malignant diagnosis after surgery. A combination of cytology and molecular testing showed significant improvement in the diagnostic accuracy and allowed better prediction of malignancy in the nodules with indeterminate cytology.

CONCLUSIONS

These results indicate that molecular testing of thyroid nodules for a panel of mutations can be effectively performed in a clinical setting. It enhances the accuracy of FNA cytology and is of particular value for thyroid nodules with indeterminate cytology.

Pharmacodynamic Effect of Iopanoic Acid on Free T3 and T4 Levels in Amiodarone-induced Thyrotoxicosis

We describe the effects of iopanoic acid on daily levels of free triiodothyronine (FT3) and free thyroxine (FT4) in a patient with progressive type II amiodarone-induced thyrotoxicosis (AIT) who was undergoing thyroidectomy. The patient was a 59-year-old man who was undergoing amiodarone therapy while awaiting cardiac transplantation; the use of beta blockers and corticosteroids to control the AIT was contraindicated in this patient. Prior to thyroidectomy, the patient was started on iopanoic acid at 1.0 g twice a day; in response to gastrointestinal side effects, the dosage was subsequently reduced to 0.5 g twice a day. The patient responded to iopanoic acid with a rapid decrease in his FT3 level and slight increase in his FT4 level. This control of thyrotoxicosis allowed for an uneventful thyroidectomy, which was later followed by successful cardiac transplantation. Based on our findings in this single case, we believe that iopanoic can be used to rapidly lower FT3 levels and to treat symptoms of thyrotoxicosis in a preoperative setting. We also discuss the different pharmacodynamic effects that iopanoic acid has on FT3 and FT4 levels.

Pharmacodynamic effect of iopanoic acid on free T(3) and T(4) levels in amiodarone-induced thyrotoxicosis

We describe the effects of iopanoic acid on daily levels of free triiodothyronine (FT(3)) and free thyroxine (FT(4)) in a patient with progressive type II amiodarone-induced thyrotoxicosis (AIT) who was undergoing thyroidectomy. The patient was a 59-year-old man who was undergoing amiodarone therapy while awaiting cardiac transplantation; the use of beta blockers and corticosteroids to control the AIT was contraindicated in this patient. Prior to thyroidectomy, the patient was started on iopanoic acid at 1.0 g twice a day; in response to gastrointestinal side effects, the dosage was subsequently reduced to 0.5 g twice a day. The patient responded to iopanoic acid with a rapid decrease in his FT(3) level and slight increase in his FT(4) level. This control of thyrotoxicosis allowed for an uneventful thyroidectomy, which was later followed by successful cardiac transplantation. Based on our findings in this single case, we believe that iopanoic can be used to rapidly lower FT(3) levels and to treat symptoms of thyrotoxicosis in a preoperative setting. We also discuss the different pharmacodynamic effects that iopanoic acid has on FT(3) and FT(4) levels.

The Effects of Surgery for Primary Hyperparathyroidism

Objective

Investigate the effects of parathyroidectomy vs. medical observation for patents with asymptomatic primary hyperparathyroidism (pHP).

Methods

A meta-analysis of randomized controlled trials was performed. Outcome parameters include biochemistries and bone density of the lumbar spine, femoral neck, and distal radius. Also, health-related quality of life (HRQOL) as measured by validated instruments was analyzed.

Results

A total of 5 trials involving 345 patients (163 observed, 182 surgery) were analyzed for serum calcium, 24-hour urine calcium, and serum PTH levels. Surgical treatment produced a significant decrease in all of these parameters. Mean serum and 24-hour urine calcium levels decreased from 10.6 mg/dl to 9.4 mg/dl (p<0.001), and 253 mg/d to 148 mg/d (p<0.001) respectively. Similarly, a significant decrease in serum PTH by 58 pg/ml (p<0.001) was observed. After analyzing 7 RCT involving 531 patients, bone density in both the lumbar spine [odds ratio 2.29 (1.37 – 3.85) p<0.01] and femoral neck [odds ratio 1.84 (1.106 – 3.066) p<0.02] demonstrated statistically significant improvement 2 years after parathyroidectomy when compared to observed patients. The difference in bone density of the radius did not reach statistical significance. Narrative interpreted data was available on three RCT regarding HRQOL. Primary data from authors has been requested to allow for complete analysis of this parameter.

Conclusions

For patients with asymptomatic primary hyperparathyroidism, parathyroidectomy results in a significant improvement in lumbar spine and femoral neck bone density, as well as a normalization of chemistries. HRQOL is similarly expected to be improved, however, qualitative data to support this is pending.

Causes and consequences of hyperglycemia in critical illness

PURPOSE OF REVIEW

This article reviews recent epidemiologic and intervention studies addressing the impact of hyperglycemia on morbidity and mortality in critically ill patients. It also discusses a growing body of literature examining why elevated blood glucose occurs in hospitalized patients without previously recognized diabetes.

RECENT FINDINGS

Hyperglycemia is highly prevalent in the intensive care unit. Numerous observational studies have demonstrated the association between hyperglycemia and adverse outcomes, independent of pre-existing diabetes. Intervention trials of insulin therapy are limited but overall demonstrate that glucose lowering significantly improves outcomes. The ideal target for blood glucose and the population that would benefit most from intervention remain controversial. Less frequently studied than the consequences, the causes of hyperglycemia occurring during critical illness remain unclear. Although glucose abnormalities in hospitalized patients have traditionally been explained by mediators of stress, a growing body of evidence has examined whether underlying defects in glucose metabolism may also be important contributors.

SUMMARY

In general, evidence suggests that hyperglycemia is a potentially correctable abnormality that has deleterious effects in critically ill individuals. Hyperglycemic patients without previously recognized diabetes appear to be particularly vulnerable, and thus further examination of the mechanisms underlying the development of elevated blood glucose is warranted.

Impact of clinical reminder redesign on learnability, efficiency, usability, and workload for ambulatory clinic nurses

OBJECTIVE

Computerized clinical reminders (CRs) were designed to reduce clinicians' reliance on their memory and to present evidence-based guidelines at point of care. However, the literature indicates that CR adoption and effectiveness has been variable. We examined the impact of four design modifications to CR software on learnability, efficiency, usability, and workload for intake nursing personnel in an outpatient clinic setting. These modifications were included in a redesign primarily to address barriers to effective CR use identified during a previous field study.

DESIGN

In a simulation experiment, 16 nurses used prototypes of the current and redesigned system in a within-subject comparison for five simulated patient encounters. Prior to the experimental session, participants completed an exploration session, where "learnability" of the current and redesigned systems was assessed.

MEASUREMENTS

Time, performance, and survey data were analyzed in conjunction with semi-structured debrief interview data.

RESULTS

The redesign was found to significantly increase learnability for first-time users as measured by time to complete the first CR, efficiency as measured by task completion time for two of five patient scenarios, usability as determined by all three groupings of questions taken from a commonly used survey instrument, and two of six workload subscales of the NASA Task Load Index (TLX) survey: mental workload and frustration.

CONCLUSION

Modest design modifications to existing CR software positively impacted variables that likely would increase the willingness for first-time nursing personnel to adopt and consistently use CRs.

Amiodarone-induced thyrotoxicosis and thyroid cancer: clinical, immunohistochemical, and molecular genetic studies of a case and review of the literature

Amiodarone-induced thyrotoxicosis (AIT) is a well-known complication of amiodarone treatment found in 3% to 12% of patients. Two types of AIT have been described, each associated with a distinct histologic pattern of thyroid involvement. Type 1, which typically develops in the background of pre-existing thyroid disease, is due to iodine-induced excess thyroid hormone synthesis, whereas type 2 is due to destructive thyroiditis. The prevalence of thyroid cancer in patients with AIT is unknown. We report a case of papillary thyroid carcinoma associated with type 2 AIT.

The role of second-look nasal endoscopy after pediatric functional endoscopic sinus surgery

OBJECTIVE

To determine if second-look nasal endoscopy (SLE) improves clinical outcome after pediatric functional endoscopic sinus surgery (FESS).

DESIGN

A retrospective review was performed for all patients who had undergone FESS between January 1993 and December 1994. The patients were divided into 2 groups: those who underwent SLE 2 to 3 weeks after FESS (n=94) and those who did not undergo SLE after FESS (n=53). Patients with a history of cystic fibrosis, bone marrow transplantation, or isolated sphenoidal sinus disease were excluded from the study.

SETTING

Pediatric tertiary care hospital.

PATIENTS

All patients had a diagnosis of chronic rhinosinusitis, had failed medical therapy, and had subsequently undergone FESS.

MAIN OUTCOME MEASURES

The need for revision sinus surgery was used as the definition for poor clinical outcome, indicating that sinus disease recurred or was persistent. The number of patients requiring revision sinus surgery in each group was compared.

RESULTS

Revision surgery was performed in 20 of the 94 patients who underwent SLE after FESS. Revision surgery was performed in 10 of the 53 patients who did not undergo SLE after FESS. Six patients in the "no-second-look group" underwent follow-up nasal endoscopy at some time after the initial FESS. There was no significant difference in terms of clinical outcome between the 2 groups.

CONCLUSIONS

The rate of revision sinus surgery was comparable in those patients who underwent SLE after FESS and those who did not. The usefulness and application of SLE need to be considered carefully.